Provider Demographics
NPI:1821318676
Name:COLLICA, JUDITH JO (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:JO
Last Name:COLLICA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1021 KARL GREIMEL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-9465
Mailing Address - Country:US
Mailing Address - Phone:810-220-3766
Mailing Address - Fax:810-225-8702
Practice Address - Street 1:1021 KARL GREIMEL DR STE 100
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-9465
Practice Address - Country:US
Practice Address - Phone:810-220-3766
Practice Address - Fax:810-225-8702
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4074070674363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics